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1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
3Pituitary Center, Seoul National University Hospital, Seoul, Korea
4Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
Copyright © 2024 Korean Endocrine Society
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.
AUTHOR CONTRIBUTIONS
Conception or design: J.C., J.H.K., Y.H.K., J.L. Acquisition, analysis, or interpretation of data: J.C., J.H.K., Y.H.K., J.L. Drafting the work or revising: J.C., J.H.K., Y.H.K., J.L. Final approval of the manuscript: J.C., J.H.K., Y.H.K., J.L.
Values are expressed as median (interquartile range) or number (%).
OSA, obstructive sleep apnea; REI, respiratory event index; BMI, body mass index; STOP-Bang, Snoring, Tiredness, Observed apnea, high blood Pressure-Body mass index, Age, Neck circumference, and Gender; GH, growth hormone; OGTT, oral glucose tolerance test; IGF-1, insulin-like growth factor 1; ULN, upper limit of normal; ACTH, adrenocorticotropic hormone; TSH, thyroid-stimulating hormone; HbA1c, glycated hemoglobin; SpO2, oxygen saturation; TS90, sleep time spent with oxygen saturation <90%; ODI, oxygen desaturation index.
STOP-Bang, Snoring, Tiredness, Observed apnea, high blood Pressure-Body mass index, Age, Neck circumference, and Gender; OSA, obstructive sleep apnea; CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value; REI, respiratory event index; ESS, Epworth Sleepiness Scale.
Parameter | Before surgery | After surgery | Median difference (95% CI)a | P value |
---|---|---|---|---|
REI, /hr | 12.2 (4.3–25.6) | 4.3 (2.3–6.9) | –9.5 (–13.3 to –5.3) | <0.001 |
Supine REI, /hr | 18.7 (9.9–36.0) | 7.4 (4.1–16.1) | –12.0 (–18.9 to –7.4) | <0.001 |
ODI, /hr | 13.0 (4.9–25.1) | 4.5 (2.7–6.9) | –10.0 (–13.9 to –5.7) | <0.001 |
Supine ODI, /hr | 17.2 (11.0–37.7) | 6.6 (3.5–18.2) | –13.2 (–20.0 to –7.9) | <0.001 |
TS90, min | 2.3 (0.2–12.5) | 0.3 (0.0–2.0) | –4.8 (–13.5 to –0.9) | 0.002 |
TS90, % | 0.5 (0.0–3.0) | 0.1 (0.0–0.4) | –1.4 (–3.2 to –0.3) | 0.002 |
Mean SpO2, % | 94.8 (93.8–95.7) | 95.6 (94.7–96.7) | 0.9 (0.6 to 1.2) | <0.001 |
Lowest SpO2, % | 85.0 (80.5–89.0) | 88.0 (85.0–90.0) | 4.0 (2.0 to 5.0) | <0.001 |
Mean apnea duration, sec | 20.6 (15.4–24.5) | 21.0 (16.9–29.2) | 0.6 (–3.5 to 4.9) | 0.786 |
Longest apnea duration, sec | 34.1 (24.3–45.7) | 27.9 (21.1–47.3) | –3.3 (–11.1 to 4.8) | 0.313 |
Epworth Sleepiness Scale | 8 (4–10) | 6 (4–8) | –2 (–4 to 5) | 0.076 |
Weight, kg | 68.5 (58.2–79.6) | 69.7 (58.8–79.3) | –0.4 (–1.4 to 0.5) | 0.368 |
Neck circumference, cm | 37.5 (34.0–40.5) | 36.0 (33.0–39.2) | –1.0 (–1.5 to –0.5) | 0.002 |
TSH, μIU/mL | 1.0 (0.7–1.6) | 1.1 (0.7–2.1) | 0.1 (–0.1 to 0.3) | 0.252 |
Free T4, ng/dL | 1.1 (1.1–1.2) | 1.2 (1.1–1.3) | 0.1 (0.01 to 0.1) | 0.014 |
GH, ng/mL | 14.3 (5.1–28.0) | 0.3 (0.1–1.2) | –15.9 (–20.7 to –10.4) | <0.001 |
Nadir GH during OGTT, ng/mL | 6.0 (3.3–22.1) | 0.2 (0.1–0.5) | –11.4 (–15.3 to –5.1) | <0.001 |
IGF-1, ng/mL | 615.0 (492.0–792.0) | 204.0 (134.0–263.5) | –404.1 (–497.0 to –323.0) | <0.001 |
IGF-1, ×ULN | 2.0 (1.5–2.4) | 0.6 (0.5–0.8) | –1.3 (–1.6 to –1.1) | <0.001 |
Values are expressed as median (interquartile range). P value from the Wilcoxon signed-rank test.
CI, confidence interval; REI, respiratory event index; ODI, oxygen desaturation index; TS90, sleep time spent with oxygen saturation <90%; SpO2, oxygen saturation; TSH, thyroid-stimulating hormone; T4, thyroxine; GH, growth hormone; OGTT, oral glucose tolerance test; IGF-1, insulin-like growth factor 1; ULN, upper limit of normal.
a Median difference (95% CI) from the Hodges-Lehmann estimator.
Model 1 adjusted for age and baseline REI that were selected by the Lasso method among preoperative variables at baseline; Model 2 adjusted for baseline REI and change in IGF-1 levels that were selected by the Lasso method among preoperative and postoperative variables.
CI, confidence interval; REI, respiratory event index; IGF-1, insulin-like growth factor 1; ULN, upper limit of normal.
Characteristic | All patients (n=35) | Patients with OSA (REI ≥5/hr) (n=24) | Patients without OSA (REI <5/hr) (n=11) | P value |
---|---|---|---|---|
Age at enrolment, yr | 47.0 (36.0–53.0) | 48.5 (38.0–54.5) | 46.0 (26.5–50.0) | 0.160 |
Male sex | 14 (40.0) | 9 (37.5) | 5 (45.5) | 0.721 |
Never smoker | 23 (65.7) | 14 (58.3) | 9 (81.8) | 0.259 |
Weight, kg | 68.5 (59.5–79.6) | 71.0 (61.6–79.6) | 67.0 (56.5–82.3) | 0.657 |
BMI, kg/m2 | 24.4 (22.4–26.1) | 24.9 (23.4–26.5) | 22.1 (21.8–24.8) | 0.060 |
Neck circumference, cm | 37.5 (34.0–40.5) | 37.0 (34.0–40.2) | 38.0 (33.0–40.8) | 0.789 |
Friedman tongue position | ||||
Grade I | 3 (8.6) | 1 (4.2) | 2 (18.2) | 0.433 |
Grade II | 2 (5.7) | 1 (4.2) | 1 (9.1) | |
Grade III | 11 (31.4) | 8 (33.3) | 3 (27.3) | |
Grade IV | 19 (54.3) | 14 (58.3) | 5 (45.5) | |
Friedman tonsil size | 0.689 | |||
1 | 25 (71.4) | 18 (75.0) | 7 (63.6) | |
2 | 10 (28.6) | 6 (25.0) | 4 (36.4) | |
Symptoms of OSA | ||||
Habitual snoring | 33 (94.3) | 23 (95.8) | 10 (90.9) | 0.536 |
Witnessed apnea | 16 (45.7) | 11 (45.8) | 5 (45.5) | >0.999 |
Excessive daytime sleepiness | 22 (62.9) | 15 (62.5) | 7 (63.6) | >0.999 |
Non-restorative sleep | 26 (74.3) | 18 (75.0) | 8 (72.7) | >0.999 |
Fatigue | 25 (71.4) | 17 (70.8) | 8 (72.7) | >0.999 |
Insomnia symptoms | 9 (25.7) | 5 (20.8) | 4 (36.4) | 0.416 |
STOP-Bang questionnaire | 3 (3–5) | 4 (3–5) | 3 (2–4) | 0.276 |
Epworth Sleepiness Scale | 8 (4–10) | 7 (4–10) | 8 (4–11) | 0.957 |
Comorbidities | ||||
Diabetes mellitus | 7 (20.0) | 5 (20.8) | 2 (18.2) | >0.999 |
Hypertension | 10 (28.6) | 8 (33.3) | 2 (18.2) | 0.447 |
Dyslipidemia | 5 (14.3) | 4 (16.7) | 1 (9.1) | >0.999 |
Cardiovascular disease | 1 (2.9) | 1 (4.2) | 0 | >0.999 |
Stroke | 2 (5.7) | 2 (8.3) | 0 | >0.999 |
Osteoporosis | 4 (11.4) | 3 (12.5) | 1 (9.1) | >0.999 |
Cancer | 7 (20.0) | 6 (25.0) | 1 (9.1) | 0.392 |
Arthralgia | 6 (17.1) | 5 (20.8) | 1 (9.1) | 0.640 |
Carpal tunnel syndrome | 3 (8.6) | 3 (12.5) | 0 | 0.536 |
Tumor characteristics | ||||
Maximal tumor size, cm | 2.0 (1.3–2.5) | 1.8 (1.4–2.5) | 2.0 (1.2–2.8) | 0.766 |
Macroadenoma (≥1 cm) | 31 (88.6) | 22 (91.7) | 9 (81.8) | 0.575 |
Cavernous sinus invasion | 11 (31.4) | 8 (33.3) | 3 (27.3) | >0.999 |
Optic chiasm compression | 5 (14.3) | 3 (12.5) | 2 (18.2) | 0.640 |
Hormone and metabolic parameters | ||||
GH, ng/mL | 14.3 (5.1–28.0) | 15.2 (5.1–30.0) | 11.5 (5.2–26.0) | 0.540 |
Nadir GH during OGTT, ng/mL | 6.0 (3.6–22.1) | 6.2 (3.0–19.4) | 5.2 (3.8–28.9) | 0.582 |
IGF-1, ng/mL | 615.0 (492.0–792.0) | 632.5 (530.0–856.5) | 501.0 (349.5–640.0) | 0.040 |
IGF-1, ×ULN | 2.0 (1.5–2.4) | 2.2 (1.6–2.6) | 1.3 (1.2–1.9) | 0.003 |
Prolactin, ng/mL | 7.1 (5.2–21.5) | 6.8 (5.2–23.4) | 7.7 (5.6–21.5) | 0.845 |
ACTH deficiency | 1 (2.9) | 1 (4.2) | 0 | >0.999 |
TSH deficiency | 2 (5.7) | 1 (4.2) | 1 (9.1) | 0.536 |
Gonadotropin deficiency | 11 (31.4) | 9 (37.5) | 2 (18.2) | 0.435 |
Fasting plasma glucose, mg/dL | 103.0 (94.5–111.0) | 102.0 (95.5–112.0) | 104.0 (92.0–105.0) | 0.557 |
2-hour postprandial plasma glucose, mg/dL | 138.0 (110.5–199.0) | 151.0 (114.0–216.0) | 138.0 (109.0–157.5) | 0.558 |
HbA1c, % | 6.1 (5.6–6.4) | 6.1 (5.7– 6.4) | 5.8 (5.6–6.5) | 0.432 |
Parameters of respiratory polygraphy | ||||
REI, /hr | 12.2 (4.3–25.6) | 19.6 (12.1–27.9) | 3.4 (3.0–4.2) | <0.001 |
Supine REI, /hr | 18.7 (9.9–36.0) | 29.8 (15.6–45.1) | 6.1 (4.2–9.9) | <0.001 |
Non-supine REI, /hr | 2.0 (0.5–9.3) | 4.8 (0.6–18.8) | 1.0 (0.1–1.9) | 0.030 |
Mean apnea duration, sec | 20.6 (15.4–24.5) | 21.8 (18.0–25.6) | 16.3 (13.5–19.4) | 0.036 |
Longest apnea duration, sec | 34.1 (24.3–45.7) | 40.9 (32.6–50.6) | 22.6 (16.4–28.6) | 0.001 |
Mean SpO2, % | 94.8 (93.8–95.7) | 94.7 (93.1–95.7) | 95.3 (94.8–96.0) | 0.126 |
Lowest SpO2, % | 85.0 (80.5–89.0) | 83.0 (72.5–87.0) | 88.0 (86.0–89.5) | 0.003 |
TS90, min | 2.3 (0.2–12.5) | 5.8 (1.2–24.9) | 0.2 (0.0–0.6) | 0.001 |
TS90, % | 0.5 (0.0–3.0) | 1.2 (0.3–5.6) | 0.1 (0.0–0.2) | 0.002 |
ODI, /hr | 13.0 (4.9–25.1) | 20.0 (12.8–30.7) | 3.9 (3.1–4.5) | <0.001 |
Supine ODI, /hr | 17.2 (11.0–37.7) | 32.2 (15.8–43.5) | 6.3 (4.2–10.6) | <0.001 |
Non-supine ODI, /hr | 4.1 (1.0–13.5) | 6.8 (1.0–17.8) | 2.7 (1.1–3.8) | 0.131 |
No. (%) | Sensitivity (95% CI) | Specificity (95% CI) | PPV (95% CI) | NPV (95% CI) | |
---|---|---|---|---|---|
All OSA, REI ≥5/hr | |||||
STOP-Bang ≥3 | 27 (77.1) | 79.2 (57.8–92.9) | 27.3 (6.0–61.0) | 70.4 (49.8–86.2) | 37.5 (8.5–75.5) |
ESS >10 | 9 (25.7) | 20.8 (07.1–42.2) | 63.6 (30.8–89.1) | 55.6 (21.2–86.3) | 26.9 (11.6–47.8) |
Moderate-to-severe OSA, REI ≥15/hr | |||||
STOP-Bang ≥3 | 27 (77.1) | 93.3 (68.1–99.8) | 35.0 (15.4–59.2) | 51.9 (31.9–71.3) | 87.5 (47.3–99.7) |
ESS >10 | 9 (25.7) | 26.7 (7.8–55.1) | 75.0 (50.9–91.3) | 44.4 (13.7–78.8) | 57.7 (36.9–76.6) |
Severe OSA, REI ≥30/hr | |||||
STOP-Bang ≥3 | 27 (77.1) | 75.0 (19.4–99.4) | 22.6 (9.6–41.1) | 11.1 (2.4–29.2) | 87.5 (47.3–99.7) |
ESS >10 | 9 (25.7) | 25.0 (0.6–80.6) | 74.2 (55.4–88.1) | 11.1 (0.3–48.2) | 88.5 (69.8–97.6) |
Parameter | Before surgery | After surgery | Median difference (95% CI) |
P value |
---|---|---|---|---|
REI, /hr | 12.2 (4.3–25.6) | 4.3 (2.3–6.9) | –9.5 (–13.3 to –5.3) | <0.001 |
Supine REI, /hr | 18.7 (9.9–36.0) | 7.4 (4.1–16.1) | –12.0 (–18.9 to –7.4) | <0.001 |
ODI, /hr | 13.0 (4.9–25.1) | 4.5 (2.7–6.9) | –10.0 (–13.9 to –5.7) | <0.001 |
Supine ODI, /hr | 17.2 (11.0–37.7) | 6.6 (3.5–18.2) | –13.2 (–20.0 to –7.9) | <0.001 |
TS90, min | 2.3 (0.2–12.5) | 0.3 (0.0–2.0) | –4.8 (–13.5 to –0.9) | 0.002 |
TS90, % | 0.5 (0.0–3.0) | 0.1 (0.0–0.4) | –1.4 (–3.2 to –0.3) | 0.002 |
Mean SpO2, % | 94.8 (93.8–95.7) | 95.6 (94.7–96.7) | 0.9 (0.6 to 1.2) | <0.001 |
Lowest SpO2, % | 85.0 (80.5–89.0) | 88.0 (85.0–90.0) | 4.0 (2.0 to 5.0) | <0.001 |
Mean apnea duration, sec | 20.6 (15.4–24.5) | 21.0 (16.9–29.2) | 0.6 (–3.5 to 4.9) | 0.786 |
Longest apnea duration, sec | 34.1 (24.3–45.7) | 27.9 (21.1–47.3) | –3.3 (–11.1 to 4.8) | 0.313 |
Epworth Sleepiness Scale | 8 (4–10) | 6 (4–8) | –2 (–4 to 5) | 0.076 |
Weight, kg | 68.5 (58.2–79.6) | 69.7 (58.8–79.3) | –0.4 (–1.4 to 0.5) | 0.368 |
Neck circumference, cm | 37.5 (34.0–40.5) | 36.0 (33.0–39.2) | –1.0 (–1.5 to –0.5) | 0.002 |
TSH, μIU/mL | 1.0 (0.7–1.6) | 1.1 (0.7–2.1) | 0.1 (–0.1 to 0.3) | 0.252 |
Free T4, ng/dL | 1.1 (1.1–1.2) | 1.2 (1.1–1.3) | 0.1 (0.01 to 0.1) | 0.014 |
GH, ng/mL | 14.3 (5.1–28.0) | 0.3 (0.1–1.2) | –15.9 (–20.7 to –10.4) | <0.001 |
Nadir GH during OGTT, ng/mL | 6.0 (3.3–22.1) | 0.2 (0.1–0.5) | –11.4 (–15.3 to –5.1) | <0.001 |
IGF-1, ng/mL | 615.0 (492.0–792.0) | 204.0 (134.0–263.5) | –404.1 (–497.0 to –323.0) | <0.001 |
IGF-1, ×ULN | 2.0 (1.5–2.4) | 0.6 (0.5–0.8) | –1.3 (–1.6 to –1.1) | <0.001 |
Effect | Model 1 |
Model 2 |
||
---|---|---|---|---|
Estimate | 95% CI | Estimate | 95% CI | |
Time (before vs. after surgery) | –10.3 | –13.2 to –7.5 | - | - |
Age at enrolment, yr | 0.1 | –0.1 to 0.2 | - | - |
Baseline REI, /hr | 0.6 | 0.5 to 0.7 | 0.6 | 0.5 to 0.7 |
IGF-1 change, ×ULN | - | - | 2.9 | 1.6 to 4.1 |
Values are expressed as median (interquartile range) or number (%). OSA, obstructive sleep apnea; REI, respiratory event index; BMI, body mass index; STOP-Bang, Snoring, Tiredness, Observed apnea, high blood Pressure-Body mass index, Age, Neck circumference, and Gender; GH, growth hormone; OGTT, oral glucose tolerance test; IGF-1, insulin-like growth factor 1; ULN, upper limit of normal; ACTH, adrenocorticotropic hormone; TSH, thyroid-stimulating hormone; HbA1c, glycated hemoglobin; SpO2, oxygen saturation; TS90, sleep time spent with oxygen saturation <90%; ODI, oxygen desaturation index.
STOP-Bang, Snoring, Tiredness, Observed apnea, high blood Pressure-Body mass index, Age, Neck circumference, and Gender; OSA, obstructive sleep apnea; CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value; REI, respiratory event index; ESS, Epworth Sleepiness Scale.
Values are expressed as median (interquartile range). CI, confidence interval; REI, respiratory event index; ODI, oxygen desaturation index; TS90, sleep time spent with oxygen saturation <90%; SpO2, oxygen saturation; TSH, thyroid-stimulating hormone; T4, thyroxine; GH, growth hormone; OGTT, oral glucose tolerance test; IGF-1, insulin-like growth factor 1; ULN, upper limit of normal. Median difference (95% CI) from the Hodges-Lehmann estimator.
Model 1 adjusted for age and baseline REI that were selected by the Lasso method among preoperative variables at baseline; Model 2 adjusted for baseline REI and change in IGF-1 levels that were selected by the Lasso method among preoperative and postoperative variables. CI, confidence interval; REI, respiratory event index; IGF-1, insulin-like growth factor 1; ULN, upper limit of normal.